EMR / EHR

Digital dilemma

Driven by CCHIT certification, meaningful use and ARRA/HITECH incentive programs, the purchase of electronic health records/electronic medical records systems is looming large on many hospitals' horizons — most likely for this fiscal year.

According to a report recently released by the American College of Physicians, "Increasing the use of quality measurement as part of EHR systems is critical to achieving meaningful use of health information technology."

For our annual resource guide issue, Health Management Technology reached out to several experts to find out what is most important when considering the purchase of an EMR/EHR system.

"Clearly, the biggest driver of EMR/EHR interest and adoption is the stimulus package and the realization that there is assistance to pay for technology that can improve clinical and financial outcomes — and the looming reality of penalties for non-adoption," says Betty Otter-Nickerson, president of Sage Healthcare.

Questions about meaningful-use requirements are a potential stumbling block for prospective EMR/EHR buyers.

Steven Emery

Says Steven Emery, director of product management, HealthPort, "Physicians are receiving a lot of messages about using government funding to pay for EMRs/EHRs. Yet many, if not most, are hesitant to purchase systems under these conditions, because the meaningful-use requirements are somewhat daunting. Many physicians are holding off until they understand the final rule on what they will be required to do if they accept this money, and also to make sure they are choosing a vendor with staying power and the technology that will allow them to meet these requirements."

Rohit Nayak, vice president of physician technology solutions, MedPlus, agrees that meaningful-use reimbursements remain the largest impetus for EMR/EHR purchase, while patients and payers are key influencers in the decision to adopt.

Money talks Funding is a main driving force in determining whether to buy, according to Glenn Keet, president, Axolotl. "There are many knowledgeable consultants who focus their efforts on researching what differentiates HIE and EMR/EHR vendors," he says. "These consultants are able to assist in finding the right vendor to fit anyone's needs."

Rohit Nayak

Selecting an EMR/EHR from so many vendors competing in the marketplace can be daunting; it's what Ryan Howard, CEO of Practice Fusion, calls "analysis paralysis."

Ryan Howard

"It is so difficult to get price quotes and demos from most vendors," Howard says. "It's a confusing process for buyers, especially those who may be looking at health IT for the first time."

Rick Jung, chief operations officer of Medsphere Systems, states that many U.S. hospitals can't afford EHR systems. "If they could, more ... hospitals would have an EHR today after 20 years of marketing," he says. "They can't afford the huge upfront costs and the regular add-ons for interfaces, upgrades and support that make it impossible to determine the true total cost of ownership."

Because of this, it is important to ask vendors to disclose the full cost of the EMR/EHR, explains Howard. "Some vendors may present an initial licensing fee, but there may be other hidden costs for training, support or updates," he says. "These costs can add up in a short period of time."

All of the vendor experts we interviewed for this article say their products offer support for the transition from ICD-9 to ICD-10, as well as maintenance and technical support for their customers. Cost of systems and timeframe of implementation all vary widely, depending on the size of the practice and number of locations and providers.

Outside help Once the decision has been made to purchase an EMR/EHR, our experts suggest that potential buyers look to outside resources to help them choose the proper system for their practice, size and work flow.

"To a very large extent, physician buying decisions are influenced by other physicians," says Otter-Nickerson. "Physicians who have gone through experiences — good and bad — of implementing EMR/EHR are the best resources. Speaking and visiting with these practices is a great way to benefit from their experience."

And outside help for selecting the proper EMR/EHR can come from a veritable plethora of sources.

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"Beyond gathering information on available systems through Internet searches, tradeshows, advertising and various vendor promotions," Emery says, "networking with peers, and asking a practice of similar size and makeup what system they are using and their likes and dislikes, is probably the most powerful decision-making tool."

Dave Miller, chief security officer, Covisint, states that the two most helpful resources for prospective buyers are industry analyst firms and "referrals from others who've faced the same situation and resolved it, showing quantifiable and/or qualitative gains."

Rick Jung

Dave Miller

Nayak concurs, noting that references from peers who have successfully deployed similar EMR/EHR solutions are extremely valuable, as are knowledge of vendors' experience and status in the marketplace. Vendor track records and the opinions of other users are extremely helpful in selecting an EMR/EHR, agrees Robert Mayer, CIO, State of New Mexico.

Howard recommends researching products through social media Web sites. "Research through Facebook, Twitter, or YouTube can be invaluable when selecting an EMR/EHR," he offers. "While some vendors can provide a comprehensive overview of their product, sometimes there is missing information directly from the source. We recommend asking around. With word-of-mouth, physicians can hear from other physicians, in practices similar to theirs, on whether an EMR/EHR has worked for them."

Second, Howard suggests that prospective buyers find out what percentage of physicians using the EMR/EHR they are considering are in solo practices or small groups similar to theirs. "What may work for a hospital physician may be poorly suited for the work flow in a small or solo practice," he says.

Robert Mayer

This doesn't necessarily mean buying the same EMR/EHR as a peer, says Otter-Nickerson. "It also has to do with learning about the process and best practices of selecting and implementing an EMR/EHR in a way that minimizes problems and set-backs and maximizes the advantages this technology has to offer."

Howard says it's a good idea to ask the EMR/EHR vendor for instances in which users made a recommendation for improvement in the EMR/EHR and how that request was implemented into the system. "This will not only give the practice a good idea of the extent to which the vendor cares about their customers," he says, "but also whether their technology architecture will accommodate rapid improvement cycles."

Our experts agree it is always important to gather the most information possible from vendors about their products before a purchase is made.

"CIOs who demand evidence rather than brochures from their vendors — proof points related to adoption and automation, clinical transformation and total cost of ownership — will be better equipped to choose an EHR that is safe for their hospital and their career," Jung says.

H.T. Snowday, chief technology officer, Versus Technology, says the best bet when considering purchasing any healthcare IT product or service is to look to peers. "If it's a product, I like to talk to others, maybe look at online reviews," he says. "If it's a service, I like to see it in action, live (not a demo), or speak with a customer. Quality is always important. So is good customer service. It's also wise to make sure it will work for both current and long-term plans as well, this will save heartache down the road — not to mention the financial aspect."

Maintaining productivityUnderstandably, providers want to be sure that their physicians will actually adopt and use whatever new systems are selected, and that they have enough time, money and resources to address work-flow changes, says Sharron Finlay, regional director, Beacon Partners.

"The biggest challenge is justifying the return on investment, particularly quality improvements that should save money for healthcare as a whole (i.e., duplicate tests), but lose revenue because of the reduction in the number of ancillary tests," Finlay says.

H.T. Snowday

Otter-Nickerson states that a significant number of providers are concerned that EMRs/EHRs will slow them down, make it more difficult to practice, or require changes they are unwilling to make.

"The fear of loss in productivity is enough to cause hesitation even in the most tech-savvy practices," says Emery. "In their minds, and rightfully so, minutes added to each patient can account for hours lost over the course of a week; and this, in turn, impacts financials. However, an experienced implementation team can help a practice temper expectations and offer guidance on a reasonable roll-out plan."

Otter-Nickerson states that some providers agree a temporary dip in productivity during EMR/EHR adoption is to be expected; but no provider is willing to sacrifice productivity in the long term.

"One of the biggest fears about moving from a paper medical record system to an electronic one is that the switch is going to slow you down," Howard says. "Between training and new work flows, a dip in productivity can be significant and can last a long time with some vendors. This is a concern especially in small practices, where there isn't any extra staff, time or money to waste."

Additionally, relates Nayak, it can be difficult to achieve balance between EMR/EHR implementation costs and benefits.

"So much of IT is soft ROI, so it can be exceptionally difficult to point to direct return on investment," says Snowday. "An MRI or ultrasound unit has a very clear return on investment."

The adoption processThe biggest challenges before and after the purchase and implementation of an EMR/EHR system have to do with process redesign and EMR/EHR readiness, according to Otter-Nickerson.

"Prior to the purchase, practices need to take the time to establish a culture around EMR/EHR readiness," she says. "The practice needs to designate champions within the practice; identify work flows that will need to change; and set clear goals and objectives. After go-live, it is a matter of managing change and expectations among all the stakeholders. Everybody needs to embrace change and stay focused on the outlined goals and objectives."

The question of adoptability is one that must be addressed from the beginning of the purchasing process. If the system is not adoptable, "it doesn't make sense to consider it, regardless of how many features and functions it has," Jung says. "In other words, a luxury car is only valuable if you can drive it."

Above all, the EMR/EHR must meet the needs of the practice and be easy to adopt and to use, states Nayak. "Look for low total cost of ownership — three years; minimize practice work-flow disruption during the implementation and training phase. The solutions should provide ready access to patient clinical information to eliminate paper file conversion."

And because it can be difficult to rate the performance of IT systems, checklists and benchmarks should be established so it can be determined if the EMR/EHR is performing up to standards.

"Customers always wonder how they can get out if performance is sub-par, so it's important to establish criteria for success from the outset," Snowday says. "For some purchases, it's easy to evaluate success. With other systems, customers and vendors should discuss expectations and determine how outcomes will be measured."

The future of electronic healthMoving forward, Otter-Nickerson sees the move toward widespread adoption of cloud-based computing as one of the major trends. "Mobile computing technology is obviously growing by leaps and bounds, as well," she says. "We are also hopeful that the growing ubiquity of social media and widespread adoption of EMRs/EHRs will result in meaningful patient engagement and greater transparency for patients as consumers of healthcare services."

Says Snowday, in the short term, healthcare IT purchasing will continue to be focused on EMR/EHRs — ARRA-specified systems that help healthcare receive more funding. "With IT resources, you'll work with the people you have with greater efficiency," he says. "That's where we'll see the biggest impact on healthcare; doing more with what we have or with less."